Pulmonary Infections

C. Richard Finley, Ed.D, PA-CAssociate Professor

Physician Assistant DepartmentCollege of Allied Health & Nursing

Nova Southeastern University

ObjectivesHaving access to lecture notes the attendee

should be able to:Recall the basic pathophysiology involved

with lower respiratory tract infectionsRecall the presenting signs and symptoms

of lower respiratory tract infectionsRecall the essentials of diagnosis and

treatment of lower respiratory tract infections

PneumoniaTuberculosis (TB)Influenza (Flu)Acute Bronchitis

A 44-year-old male presents to your office complaining of a “bad cough” for the past 3-4 weeks. Over the past several days he has developed a low-grade fever, chills, and night sweats. Physical exam is notable for cachexia, hypoxia, and bilateral rales with scant hemoptysis. Which of the following is the most likely diagnosis?

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2. Tuberculosis

3. Acute bronchitis

4. Influenza

5. Lung abscess

Epidemiology Pneumonia is the fourth leading cause

of death among the elderlyespecially when it develops in

connection with a long-term illness Cases of Tuberculosis in the U.S. have

declined since 1992now is being found more often among

foreign-born people age 45 and older

The Flu also can hit the elderly hardest50% of influenza-caused

hospitalizations80% of flu deaths involve elderly

Acute Bronchitis is one of the most common problems seen in clinical practicefrequently follows viral infection

Mechanics of Pulmonary Infections

In as many as half of Pneumonia cases, pathogen remains unknown

Tuberculosis is caused by a bacterium called tubercle bacilli, which can enter the body and remain dormant sometimes for years - until the

body’s immune system weakens for some reason

The Flu is a virus that’s spread “from one lung to another”—by coughing or sneezing

Smokers are at higher risk of getting acute Bronchitis

Symptoms of Pulmonary Infections

Which of the following is a hallmark symptom of bronchitis?

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2. Chills

3. Night sweats

4. Hemoptysis

5. Cough

Pneumonia Fever Cough Congestion In older patients

fever might not be presentconfused or deliriouslose control of basic functions

Tuberculosis

Fever Cough Congestion Night sweats Weight loss Fatigue

Influenza

Fever Chills Headache Muscle aches Sore throat

Runny nose Hot, moist skin Fatigue Dry cough

Acute Bronchitis

Cough is the chief complaint SOB Wheezing

Causes of Pulmonary Infections

Pneumonia Serious illness Smoking Malnutrition Surgery Repeated antibiotic therapy Aspiration due to reduced cough

reflex (food “down the wrong pipe”) The flu

Tuberculosis

Poor nutrition Alcoholism or drug addiction Immune dysfunction

disease, drugs, or aging Homelessness or imprisonment Diabetes, malignancies, chronic

renal failure

Influenza

A variety of chronic medical illnesses

Seasonal local outbreaks or epidemics

Acute Bronchitis

Often attributed to a respiratory tract virus

When purulent sputum is presentthe bacteria that cause

community-acquired pneumonias

A 35-year-old male presents to the clinic with complaints of a sore throat and a “harsh cough with chest congestion” over the past 3-5 days. He relates slight yellowish sputum production. Which of the following would confirm your suspicions?

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1. Throat culture

2. Nasal swab

3. Sputum culture

4. Chest x-ray

5. Lung biopsy

Diagnosing Pulmonary Infections

Pneumonia

Chest x-ray Blood test

Tuberculosis

Sputum Skin test to determine the presence of

“viable organisms” Chest x-ray Biopsy and examination of lung tissue Urine sample

three consecutive days

Influenza

Confirmation of an outbreak Nasal or throat swab Nasal wash Sputum exam

Acute Bronchitis

History Chest x-ray

Treating Pulmonary Infections

Your 30-year-old male patient is a household member of a patient being treated for active TB. Which of the following is an acceptable treatment regimen?

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2 months3. High-dose amoxicillin-clavulanate, 2 g

p.o. BID for 1 week4. Isoniazid (INH), once daily for 6 months5. Observation, with monthly chest x-rays

for 3 months

Pneumonia

Antimicrobials Respiratory care Drainage of fluid from the lungs and

chest cavity

Tuberculosis Isoniazid (INH) for six to 12 months Fully developed disease

A regimen of INH and 3 other for two monthsRifampin (Rifadin)Ethambutol (Myambutol)Pyrazinamide

Selected antituberculosis drugs (depending on test results) for four more months

Influenza Bedrest – aspirin – chicken soup (fluids) Oseltamivir (Tamiflu) and zanamivir

(Relenza), given within 48 hrs of symptomsTypes A & B

Amantadine (Symmetrel) and rimantadine (Flumadine)Type A CDC recommendations - resistance

Acute Bronchitis 70% to 90% of patients are treated with

antibioticstrials demonstrate little clinical benefit

High fever, chills, respiratory distress, underlying pulmonary or immunosuppressive disorders, or signs of parenchymal infectionshould be evaluated for pneumonia treated according to the guidelines for

community-acquired pneumonia

Clinical Variables/Settings Preferred Treatment Options

Outpatient therapy     

Previously healthy     

Antibiotic therapy within 3 mo

A respiratory fluoroquinolone,1 a macrolide,2 or doxycycline

A respiratory fluoroquinolone1 alone; an advanced macrolide3 plus high-dose amoxicillin4; or high-dose amoxicillin-clavulanate5

Comorbidities6     

No recent antibiotics    

 Antibiotic therapy within 3 mo

A respiratory fluoroquinolone1 or an advanced macrolide3

A respiratory fluoroquinolone,1 or an advanced macrolide3 plus a b-lactam7

Suspected aspiration pneumonia    

 Influenza with suspected bacterial superinfection

Amoxicillin-clavulanate8 or clindamycin9

A b-lactam7 or a respiratory fluoroquinolone1

Inpatient therapy     

No recent antibiotics    

 Antibiotic therapy within 3 mo

A respiratory fluoroquinolone,1 or an advanced macrolide3 plus a b-lactam7

A respiratory fluoroquinolone,1 or an advanced macrolide3 plus a b-lactam7

ICU therapy     

Pseudomonas not an issue     

Pseudomonas a concern

A b-lactam7; vancomycin plus a respiratory fluoroquinolone1; or an advanced macrolide3

An antipseudomonal agent10 plus ciprofloxacin; an antipseudomonal agent8 plus a respiratory fluoroquinolone1; or an advanced macrolide3

Which of the following does not significantly increase an individual’s risk for developing tuberculosis?

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Note: all superscript numbers in table refer to footnotes below:

1. Respiratory fluoroquinolones: levofloxacin, moxifloxacin, or gemfloxacin.

2. Macrolides: erythromycin, clarithromycin, azithromycin.3. Advanced macrolides: clarithromycin, azithromycin.4. High-dose amoxicillin, 1 g p.o. three times a day.5. High-dose amoxicillin-clavulanate, 2 g p.o. two times a day.6. Comorbidities: chronic obstructive pulmonary disease, congestive heart

failure, diabetes, renal insufficiency, malignancy.7. b-Lactam antibiotics: high-dose amoxicillin or amoxicillin-clavulanate,

cefpodoxime, cefprozil, or cefuroxime.8. Amoxicillin-clavulanate, 500 mg p.o., q. 8 hr.9. Clindamycin, 150–300 mg p.o., q. 6 hr.10. Antipseudomonal agents: piperacillin-tazobactam, imipenem,

meropenem, ceftazidime, cefepime, or aztreonam (should be chosen for b-lactam-allergic patients).